Nkenge Miller was in her early twenties when she had her first child. At the time, she was one of the only women among her circle of friends with a new baby.
“Feeling alone and having baby blues and things of that matter, was different for me, because that’s not something that any of my peers went through,” Miller said.
Her experience with the births of her own children led her to become a doula, guiding people through their pregnancies, birthing experiences and beyond. Today, Miller is a full-spectrum doula in St. Louis, Missouri, who works with clients from all experiences and walks of life.
Miller is passionate about maternal health, which is why she supports a move Missouri lawmakers are now considering regarding Medicaid coverage for pregnant women. The measure aims to improve outcomes for pregnant people and eliminate racial disparities in maternal health.
Black women in the U.S. are about three times more likely than white women to die during pregnancy or within a year of childbirth. Health policy experts say one way to help close this gap is to ensure women enrolled in Medicaid don’t lose that coverage just two months after their pregnancy.
More than 30 states have already taken this step — and Missouri may soon join them.
Right now, pregnant people in Missouri can qualify for Medicaid health coverage at a higher income threshold than for people who aren’t pregnant. But this coverage ends 60 days after pregnancy. At that point, people who don’t qualify for standard Medicaid coverage and aren't able to transition into a commercial insurance plan risk losing access to health insurance.
This is extremely concerning to Aaliyah Bailey. She’s with Pro-Choice Missouri and is also the founder of The BlackRoads Project — a campaign to invest in Black, rural communities throughout the Midwest.
“We know that many pregnancy-related health conditions do not manifest until months into the postpartum period, including mental health disorders and cardiac conditions,” Bailey said.
This legislative session, bipartisan bills have advanced in both the Missouri House and Senate that seek to expand postpartum Medicaid coverage from 60 days to 12 months. Missouri Governor Mike Parson spoke in support of the issue in his 2023 State of the State address.
“We must do better,” he said. “If we can’t get it right for the mothers and children across our state, we might as well pack our bags and let somebody else occupy these seats.”
Black, rural communities are among the most vulnerable
The rate of maternal deaths in the U.S. is higher than in other wealthy countries, according to data from the World Health Organization. And Missouri is among the worst states when it comes to maternal health outcomes, ranking 42nd in the nation for maternal mortality in 2018, with 39 deaths for every 100,000 live births.
According to the state’s Pregnancy-Associated Mortality Review, roughly two-thirds of these deaths occurred between 43 and 365 days after birth.
Since Black women are overrepresented in the Medicaid population, they’re more likely to lose coverage after 60 days in states that have not extended postpartum Medicaid coverage.
The concern is even greater for Black women in rural areas, where access to health care services can be even more limited, said Bailey, with The BlackRoads Project.
“One mistake people often make is in thinking that rural communities are only White, and that is untrue,” she said.
Bailey’s concern is backed by data on maternal health in rural communities, which is compiled in a recent state report. About a third of Missouri’s population lives in rural communities; and data suggests that Black women in rural areas are less likely than White women to receive care in facilities that are capable of meeting their specific health needs.
“Rural individuals are 60 percent more likely to experience maternal complications and mortality than their urban counterparts,” Bailey said. “Our Black, rural communities, they're extremely at risk during pregnancy.”
Mental health plays a big role in maternal health
In Missouri, and across the U.S., mental health is a leading cause of pregnancy-related deaths.
Mental health screenings beyond six weeks postpartum can be essential for parents who may be struggling with perinatal mental health disorders, according to Kim Hawley, the state lead coordinator for the Missouri chapter of Postpartum Support International. But without health insurance, these screenings may not be accessible.
“Oh, my goodness, sometimes I see moms who aren't even, who don't know that they're struggling yet with their mental health,” Hawley said. “Your baby is teeny tiny. You're just trying to get through that time.”
The lack of access to mental health screenings is only the tip of the iceberg for some communities, according to Bailey.
“Compounding that issue, in rural communities, is the lack of mental health and behavioral health resources, along with the stigma that pervades in the communities about accessing that care,” Bailey said.
St. Louis-based doula Nkenge Miller feels her experience could have been different if she had been able to access more resources.
“Having access to care and therapy, if need be, and the education that it takes to raise a child or be pregnant, it's very important,” Miller said. “In my case, I didn't have that.”
One of the measures that would extend Medicaid coverage for pregnant women from 60 days to 12 months postpartum is working its way through the legislature.
A similar provision was part of a 2022 bill that included other health care policy changes, including a measure that would decriminalize needle exchange programs. That bill died after it stalled in the Senate due to gridlock.
The 2023 measure started off as a bill focused exclusively on pregnancy Medicaid. But a slew of polarizing amendments have since been tacked on — including language that would bar public schools from requiring students to receive COVID-19 or mRNA vaccines. This has some supporters of the pregnancy Medicaid provision concerned.
Lawmakers have until 6 p.m. on May 12 to make final decisions on all legislation.
This story comes from a partnership between KBIA and Side Effects Public Media, a health reporting collaboration based at WFYI. Side Effects is a collaboration of NPR stations across the Midwest and surrounding areas, including KBIA, Iowa Public Radio, WFPL, KCUR and Ideastream Public Media.
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